Ranking Surgeon Performance After ACL Reconstruction Using the Knee Injury and Osteoarthritis Outcome Score (KOOS)...

Patient-reported outcomes (PROs) are considered the gold standard for evaluating value-based care in orthopaedics. However, there is little evidence to guide implementation of PROs for surgeon performance evaluation.

To develop a risk-adjusted surgeon performance measure using the Knee injury and Osteoarthritis Outcome Score (KOOS) for patients undergoing anterior cruciate ligament reconstruction (ACLR).

Cross-sectional study; Level of evidence, 3.

Patients (N = 1248; 662 men; mean age, 30 ± 13 years) who underwent ACLR performed by 40 surgeons between 2010 and 2018 were identified from a large, nationally representative sports medicine clinical data registry. Linear regression was used to predict change scores for each KOOS subscale (Pain, Symptoms, Activities of Daily Living [ADL], Function in Sports and Recreation, and Knee-Related Quality of Life) while adjusting for patient baseline characteristics. A risk-adjusted performance measure was calculated for each KOOS subscale as the difference between the unadjusted and the risk-adjusted predicted change score across all patients treated by a single surgeon. Surgeon-relative quartile ranking was compared across outcome subscale scores.

One-third of the patients (34%) displayed acute cartilage damage, and 56% had a meniscal injury. In the risk adjustment models, older age, presence of diabetes, current smoking status, acute cartilage damage, concurrent cartilage treatment, lower baseline Veterans RAND 12-Item Health Survey mental and physical component scores, and lower baseline Marx and KOOS subscale values all had a significant negative influence on the predicted KOOS subscale change values (P < .05 for all). Surgeon performance, ranked in quartile groups, was the same for 10 surgeons but varied by 1 to 2 quartiles for the other 30 surgeons across the different KOOS subscales.

These results showed that surgeon performance varies widely when evaluated using different KOOS subscales for patients undergoing ACLR. Based on the preliminary results and clinical perspective, the authors recommend the ADL and Symptoms subscales as the best options to differentiate surgeon performance for these patients. However, evaluation of surgeon performance may require consideration or use of a set of PROs or the development of a single index PRO that is sensitive to the range of outcome dimensions important to patients.